- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,677.35 / $5,011.87 / $5,011.87
| Professional | | $4,677.35 | $5,011.87 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $380.19 / $602.56 / $602.56
| Professional | | $380.19 | $602.56 | $602.56 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $7,585.78 / $7,585.78 / $7,585.78
| Facility | | $7,585.78 | $7,585.78 | $7,585.78 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $6,456.54 / $7,585.78 / $7,585.78
| Professional | | $6,456.54 | $7,585.78 | $7,585.78 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $630.96 / $630.96 / $5,011.87
| Facility | | $630.96 | $630.96 | $5,011.87 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,754.23 / $3,801.89 / $6,309.57
| Professional | | $2,754.23 | $3,801.89 | $6,309.57 |